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Tier 4 - Specialty drugs

Below is a list of specialty drugs currently classified in the fourth tier of the Tier 4 Formulary. This list was last updated on 3/18/08.

Anti-Infectives
CYTOVENE (brand only) Ganciclovir capsule
DECLOMYCIN (brand only) Demeclocycline tablet
NOXAFIL Posaconazole oral suspension
VFEND Voriconazole tablet, oral susp
Anticoagulants
ARIXTRA Fondaparinux injection
FRAGMIN Dalteparin injection
INNOHEP Tinzaparin injection
Antiemetics
ANZEMET Dolasetron tablet
CESAMET Nabilone capsule
KYTRIL Granisetron tablet, oral solution
Blood Modifiers
EPOGEN Epoetin alfa injection
LEUKINE Sargramostim injection
NEULASTA Pegfilgrastim injection
PROCRIT Epoetin alfa injection
Dermatology
ACCUTANE (brand only) Isotretinoin capsule
REGRANEX Becaplermin gel
Growth Hormones
GENOTROPIN Somatropin injection
OMNITROPE Somatropin injection
PROTROPIN Somatrem injection
SAIZEN Somatropin injection
SEROSTIM Somatropin injection
ZORBTIVE Somatropin injection
Hepatitis C
COPEGUS (brand only) Ribavirin tablet
REBETOL CAPSULE (brand only) Ribavirin capsule
REBETRON 1000 Interferon alfa-2b/ribavirin
REBETRON 1200 Interferon alfa-2b/ribavirin
REBETRON 600 Interferon alfa-2b/ribavirin
ROFERON-A Interferon alfa-2a
Infertility
BRAVELLE Urofollitropin injection
CETROTIDE Cetrotide injection
FERTINEX Urofollitropin injection
FOLLISTIM Follitropin beta injection
FOLLISTIM AQ Follitropin beta injection
FOLLISTIM/ANTAGON Follitropin beta/ganirelix acetate
GANIRELIX ACETATE Ganirelix acetate injection
GONAL-F Follitropin alfa injection
GONAL-F RFF Follitropin alfa injection
LUVERIS Lutropin alfa injection
MENOPUR Menotropins injection
NOVAREL (brand only Chorionic gonadotropin injection
OVIDREL Choriogonadotropin alfa injection
PERGONAL Menotropins injection
PREGNYL (brand only) Chorionic gonadotropin injection
PROFASI (brand only) Chorionic gonadotropin injection
REPRONEX Menotropins injection
Rheumatoid Arthritis / Psoriasis
ARAVA (brand only) Leflunomide tablet
HUMIRA Adalimumab injection
KINERET Anakinra injection
RAPTIVA Efalizumab injection
Oncology
FASLODEX Fulvestrant injection
LUPRON (brand only) Leuprolide acetate injection
TASIGNA Nilotinib capsule
VEPESID (brand only) Etoposide capsule
ZOLINZA Vorinostat capsule
Miscellaneous
ACTHAR H.P. Repository corticotropin injection
ACTIQ (brand only) Fentanyl lozenge
D.H.E. 45 (brand only) Dihydroergotamine injection
EXJADE Deferasirox tablets
FENTORA Fentanyl buccal tablet
FORTEO Teriparatide injection
INCRELEX Mecasermin injection
IPLEX Mecasermin rinfabate injection
REVIA (brand only) Naltrexone tablet
SOMATULINE DEPOT Lanreotide acetate injection
SYNAREL Nafarelin acetate nasal solution